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Editor—The NHS Confederation and the BMA have argued that the recent problems in dealing with emergency demand conceal more fundamental problems: the NHS has too little capacity run at too high a rate of use.1
Running hospitals at the current rates of occupancy is not efficient. Bagust et al show that hospital occupancy of more than 85% will guarantee periodic bed crises and the cancellation of hospital admissions.2 NHS occupancy information excludes patients who stay less than one day and therefore underestimates the true picture. In critical care a growing body of evidence suggests that there is insufficient spare capacity in the system.
Many NHS staff have a ridiculous workload. They are required to cope with the chaotic results of high levels of admissions and occupancy and, in particular, the problem of patients on outlying wards. There is no time for staff to muster new resources, and nurses have had the parts of their work that allowed recuperation devolved to other staff. There is growing evidence that these problems affect outcomes and lead to staff seeking employment elsewhere, further exacerbating the pressure on those staff who remain.
These problems have arisen because for 20 years the NHS has sought to do more work for less money. The measures of efficiency used by the government have in general paid little attention to the quality of the result, although there has been more of a move in this direction recently.3 The tight finances of the NHS have meant that improvements in efficiency can lead to a dilution of quality services, overstretching staff, being slow to adopt new medicines and technology, and failing to invest in major change that could improve the quality of what we do. Unfortunately, the latest planning guidance issued by the NHS Executive requires a further 3% increase in efficiency, which could make the problems worse.4
The absence of good baseline data means that it is difficult to prove that this will cause problems, and there is a danger of appearing to complain without evidence. We need to look at the way we measure performance and relate this more closely to broader measures than simple efficiency.
Footnotes
The NHS Confederation is a membership organisation that represents 95% of NHS trusts and health authorities.
References
1.Woodman R. Doctors and politicians clash over size of flu problem. BMJ. 2000;320:138. . (15 January.) [PMC free article] [PubMed] [Google Scholar]
2.Bagust A, Place M, Posnett JW. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. BMJ. 1999;319:155–158. doi: 10.1136/bmj.319.7203.155. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Department of Health. Planning for health and health care, incorporating guidance for health and local authorities on health improvement programmes, service and financial frameworks, joint investment plans and primary care investment plans. London: DoH; 1999. . (HSC 1999/244.) [Google Scholar]
Editor—In an otherwise excellent editorial on the contradiction in government policy about acute beds in the NHS, Pollock and Dunnigan describe January's flu epidemic as making life tough for British health ministers.1-1
Although the politicians wished us to believe otherwise, the number of cases of flu reported in England and Wales in January barely reached half of the 400 cases per 100 000 population defined as epidemic by public health doctors, and in reality seemed to be little more than the normal rise in cases associated with the winter.1-2 If this year's mild winter has brought the NHS to its knees a real epidemic would surely stretch it well beyond breaking point. It is a pity to see both the authors and the BMJ perpetuating disinformation put about by the government's spin doctors to minimise the plight of acute hospitals.
Editor—Last winter hospitals throughout the United Kingdom struggled hard to cope with elderly patients with respiratory infections.2-1 A high winter mortality in the United Kingdom is documented in the literature. The mean excess winter death index (defined as the percentage excess deaths in the four winter months, December to March, compared with the average in the preceding and following four months) for eight winters (1976-84) was exceptionally high in England and Wales at 21 and Scotland at 20, compared with Canada (7), Finland (8), Germany (8), and the United States (9)2-2.
During the 1996-7 winter the number of excess deaths in England and Wales was nearly 50 000, with 48% of the deaths due to respiratory infection and 36% to circulatory diseases. In the 1989-90 winter the number of deaths due to influenza alone was estimated to be over 25 000. The excess winter deaths were almost exclusively among the elderly population.2-3
The high excess winter death index in the United Kingdom is related to three potentially modifiable factors.2-2,2-4
The World Health Organization recommends a minimum indoor temperature of 18°C, but 2-3°C warmer for rooms occupied by sedentary people.2-5 Evidence suggests a lower standard of home heating in the United Kingdom,2-2 since many elderly people live in poor housing conditions and cannot afford the heating bill. Finland has invested vastly on housing improvement, including heating
People in the United Kingdom often make brief excursions into the cold outdoors environment.2-2 Efficient and free home delivery services for elderly people may help to reduce this risk
More than half of Europe adopted influenza vaccination policies based on age and covering people aged ⩾65. In the United Kingdom, however, vaccination is offered to people with chronic diseases and those living in nursing and residential homes. This leaves 5.6 million people aged ⩾65 uncovered.2-4
The winter puts more pressure on hospital staff and waiting lists every year. Keeping elderly people warm and vaccinated at home during the winter helps to reduce the burden and the consequent mortality. The cost of providing a free television licence for people over 75 might be more beneficially invested in these preventive measures.
References
2-1.Woodman R. Doctors and politicians clash over size of flu problem. BMJ. 2000;320:138. . (15 January.) [PMC free article] [PubMed] [Google Scholar]
2-2.Curwen M. Excess winter mortality: a British phenomenon. Health Trends. 1990-91;22:169–175. [Google Scholar]
2-3.Christophersen O. Mortality during 1996/7. Population Trends. 1997;90:11–17. [PubMed] [Google Scholar]
2-4.Fleming D, Charlton J, McCormick The population at risk in relation to influenza immunization policy in England and Wales. Health Trends. 1997;29(2):42–47. [Google Scholar]
2-5.Collins KJ, Exton-Smith AN. Thermal homeostasis in old age. J Am Geriatr Soc. 1983;31:519–524. [PubMed] [Google Scholar]
